New Student Registration Form
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State
Post Code
Mobile
*
E-mail
*
example@example.com
Date of Birth
Emergency Contact
*
First Name
Last Name
Mobile
*
Have you had, or do you have, any of the following
High Blood Pressure
Diabetes
Breathing Difficulties / Asthma
Heart Condition / Chest Pain
Headaches
Back Pain, Lower Back / Disc Problems
Injuries (old or new)
Recent Surgery
On Medications
Serious Allergies
If Yes to any of the above, or any other medical conditions not mentioned, please explain
At anytime during the yoga session you feel discomfort or strain it is advisable to come out of the yoga posture and take rest. It is important to listen to you body and respect its limits. I, the undersigned, understand that yoga is not a substitute for medical treatment. I recognise that it is my responsibility to notify the yoga teacher of any serious illness or injury before every class. I accept that neither the teacher nor the hosting facility is liable for any injury or damages to person or property, resulting from taking the class. Students under the age of 18 must have this form signed by a parent or guardian.
Name
First Name
Last Name
Signature
Date
-
Day
-
Month
Year
Date
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